Tuesday, December 28, 2010

The Chronic Pain Policy Coalition is a forum established in 2006 to unite patients, professionals and parliamentarians in a mission to develop an improved strategy for the prevention, treatment and management of chronic pain and its associated conditions.

PainEDU.org is supported by Endo Pharmaceuticals, Inc., King Pharmaceuticals, Inc., and Actavis Elizabeth, LLC. PainEDU is an educational website for clinicians, teaching about pain assessment and management.

As a resource for people with pain, their families and/or their caregivers, the Let's Talk Pain Coalition has created a Web-based series for them that discusses the appropriate use of opioids, over-the-counter medications and medical devices. This unique series features candid dialogues between patients, their caregivers and health care professionals about pain and its safe and effective management.

PainSAFE is an educational initiative designed to help advocate for and advance the safe use of all pain therapies. This initiative provides up-to-date information, programming and practical resources and tools to help educate people with pain and caregivers and build their self-efficacy for safely using pain treatments. A more informed consumer will result in better treatment choices, safe use of these therapies and, in turn, improve outcomes. In parallel, PainSAFE provides health care providers with a central hub of evidence-based information and practice-based tools to focus on safety and reduce the risks associated with various pain treatments.

When you enter phrases into the Google Books Ngram Viewer, it displays a graph showing how those phrases have occurred in a corpus of books (e.g., "British English", "English Fiction", "French") over the selected years.

Friday, December 24, 2010

A provocative new study called "Placebos Without Deception," published on PLoS One today, threatens to make humble sugar pills something they've rarely had a chance to be in the history of medicine: a respectable, ethically sound treatment for disease that has been vetted in controlled trials.

The word placebo is ancient, coming to us from the Latin for "I shall please."As far back as the 14th Century, the term already had connotations of fakery, sleaze, and deception. For well-to-do Catholic families in Geoffrey Chaucer's day, the custom at funerals was to offer a feast to the congregation after the mourners sang the Office for the Dead (which contains the phrase placebo Domino in regione vivorum, "I shall please the Lord in the land of the living"). The unintended effect of this largesse was to inspire distant relatives and former acquaintances of the departed to crawl out of the woodwork, weeping copiously while praising the deceased, then hastening to the buffet. By the time Chaucer wrote his Canterbury Tales, these macabre freeloaders had been christened "placebo singers."

In modern medicine, placebos are associated with another form of deception — a kind that has long been thought essential for conducting randomized clinical trials of new drugs, the statistical rock upon which the global pharmaceutical industry was built. One group of volunteers in an RCT gets the novel medication; another group (the "control" group) gets pills or capsules that look identical to the allegedly active drug, but contain only an inert substance like milk sugar. These faux drugs are called placebos.

Inevitably, the health of some people in both groups improves, while the health of others grows worse. Symptoms of illness fluctuate for all sorts of reasons, including regression to the mean. Since the goal of an RCT, from Big Pharma's perspective, is to demonstrate the effectiveness of a new drug, the return to robust health of a volunteer in the control group is considered a statistical distraction. If too many people in the trial get better after downing sugar pills, the real drug will look worse by comparison — sometimes fatally so for the purpose of earning approval from the Food and Drug Adminstration.

For a complex and somewhat mysterious set of reasons, it is becoming increasingly difficult for experimental drugs to prove their superiority to sugar pills in RCTs, which was the subject of an in-depth article I published inWired called "The Placebo Problem," recipient of this year's Kavli/AAAS Science Journalism of the Year award for a magazine feature.

Only in recent years, however, has it become obvious that the abatement of symptoms in control-group volunteers — the so-called placebo effect — is worthy of study outside the context of drug trials, and is in fact profoundly good news to anyone but investors in Pfizer, Roche, and GlaxoSmithKline. The emerging field of placebo research has revealed that the body's repertoire of resilience contains a powerful self-healing network that can help reduce pain and inflammation, lower the production of stress chemicals like cortisol, and even tame high blood pressure and the tremors of Parkinson's disease.

Jumpstarting this network requires nothing more or less than a belief that one is receiving effective treatment — in the form of a pill, a capsule, talk therapy, injection, IV, or acupuncture needle. The activation of this self-healing network is what we really mean when we talk about the placebo effect. Though inert in themselves, placebos act as passwords between the domain of the mind and the domain of the body, enabling the expectation of healing to be translated into cascades of neurotransmitters and altered patterns of brain activity that engender health.

That's all well and good, but what does it mean in the real world of people getting sick? You can hardly expect the American Medical Association to issue a wink and a nod to doctors, encouraging them to prescribe sugar pills for seriously disabling conditions like chronic depression and Parkinson's disease. Meanwhile, more and more studies each year — by researchers like Fabrizio Benedetti at the University of Turin, author of a superb new book called The Patient's Brain, and neuroscientist Tor Wager at the University of Colorado — demonstrate that the placebo effect might be potentially useful in treating a wide range of ills. Then why aren't doctors supposed to use it?

The medical establishment's ethical problem with placebo treatment boils down to the notion that for fake drugs to be effective, doctors must lie to their patients. It has been widely assumed that if a patient discovers that he or she is taking a placebo, the mind/body password will no longer unlock the network, and the magic pills will cease to do their job.

Wednesday, December 22, 2010

The compound which gives chillies their kick is being used in the fight against chronic pain.

Researchers at Aberdeen University have identified how genes are "turned on" to make humans feel pain.

Capsaicin, the compound in chillies which gives them their kick, can also turn on the switch.

It is believed the study could herald the development of new painkilling drugs.

The team looked at the mechanics of the pain gene known as substance-P which was first associated with chronic inflammatory pain more than 30 years ago.

Genes need "switches", known as promoters and enhancers, to turn them on in the right place, at the right time and at the right level.

One of the major findings of the study was that the switches do not act in isolation and need other switches to "speak to" in order to activate the gene.

Researchers based in the university's Kosterlitz Centre for Therapeutics spent five years looking for the switches that turn the substance-P gene on in a group of cells called sensory neurones.

Dr Lynne Shanley said: "Finding the switch was like looking for a needle in a haystack.

"However, by comparing the genetic sequences of humans, mice and chickens, we were able to find a short stretch of DNA that had remained unchanged since before the age of dinosaurs.

"We were delighted when this little bit of DNA turned out to be a genetic switch, or enhancer sequence, which could turn on the substance-P gene in sensory neurones."

Marissa Lear, head technician on the project, said: "Because the switch was active in these sensory neurones we applied capsaicin, the 'hot' chemical in curry and chilli, to see if the switch could be turned on and, amazingly, it was."

Chronic inflammatory pain in the form of arthritis and other conditions affects thousands of people in the UK each year and in many cases is untreatable.

Capsaicin has previously been used as treatment for chronic pain.

The scientists said understanding the genetic mechanisms that allow capsaicin to induce inflammatory pain will lead to a better understanding of the pain process.

Professor Ruth Ross, head of the Kosterlitz centre and a co-author of the paper, said: "Understanding the genetic processes that trigger inflammatory pain is essential to developing new therapies.

"Finding this new substance-P enhancer sequence, and showing that it can respond to capsaicin, has allowed us to add another part of the complex jigsaw puzzle that makes up the inflammatory pain response."

The US Drug Watchdog is urging all US adult members of Facebook, or all social networks to post a message to their friends regarding the recalled pain pills Darvocet, and Darvon, out of fear many millions of US adults could still be using these drugs. Used to treat mild to moderate pain, propoxyphene is sold by prescription under the brand names Darvon and Darvocet, a drug which also includes acetaminophen, and has been linked to potentially fatal heart rhythm abnormalities in users, heart attacks, and even death. The group says, " we received three calls this week from individuals using Darvocet, they had not heard of the recall, However, all three have had recent heart attacks." They say, "with more than 22 million users of Darvocet, or Darvon in the United States, and a recall barely a month old, our greatest worry is many to most victims, or loved ones of victims of heart rhythm abnormalities, heart attacks, or even death would have never realized that these drugs could have been the cause, or contributing factor." The US Drug Watchdog is urging Facebook, or social network users to post a message on their Facebook, or social network about the Darvocet, or Darvon recalls, with a link to the US Drug Watchdog's web site at http://USDrugWatchdog.Com

Friday, December 17, 2010

In my previous column ("Populists v. Consumers"), I suggested that "regulation" and "consumer protection" meant the same thing. That was a slight oversimplification. Regulation is supposed to mean the same thing as consumer protection, but sometimes it falls short of that ideal. In the absolute worst instances, regulators are so thoroughly captured by the interests they regulate that they create regulations more likely to harm consumers than help them. A good example at the state level surfaced on Nov. 3 when the Federal Trade Commission's Office of Policy Planning sent a letter to Patricia Shaner, general counsel for Alabama's State Board of Medical Examiners.

The FTC was troubled by a regulation that Alabama's state medical board proposed in July stating, "The interventional treatment of pain may be performed and provided only by qualified, licensed medical doctors and doctors of osteopathy" because it "constitutes the practice of medicine." The purpose of the proposed rule is to prevent nurse practitioners from doing something they've been doing in most states for a very long time: managing patients' pain.

The Alabama medical board's justification for proposing the rule is that allowing "unqualified providers" to perform interventional pain management (a category that includes "needle placement to inject drugs" through the skin, epidural injections, and injection of analgesics and anesthetics, among other procedures) "presents serious risk to patients, such as persistent or worsened pain, bleeding, infection, nerve damage, brain damage, paralysis or even death." Sounds scary, right? But as the FTC noted in its letter, Alabama has a category of nurse called a Certified Registered Nurse Anesthetist. CRNAs are trained and state-certified to perform the very tasks that the state now proposes to restrict to medical doctors. Delegating this task to nurses is hardly unusual; as anyone who's been in a hospital lately knows, it is nurses, not doctors, who typically manage pain. Doctors tend to regard pain and its treatment as a bit … pedestrian. It really only interests them as a diagnostic indicator. You want somebody to make the pain stop right away, call the nurse.

My wife died six years ago after a long illness. During one hospitalization she told a doctor making the rounds that she was in pain. The doctor replied with a lengthy monologue about what she might expect to feel after her recent procedure, and ended with the admonition that if she experienced any pain whatsoever she should be sure to tell him. An awkward silence ensued. Finally, the nurse chimed in: "She just did."

There is one category of doctors who are very interested in pain: anesthesiologists. Anesthesiologists typically enjoy predictable work schedules and earn a mean income of $211,750, compared with $63,750 for registered nurses. A study by the Lewin Group found that allowing CRNAs to provide anesthesia was especially cost-effective in rural places like ... Alabama. Unsurprisingly, the Alabama medical board's proposed rule arose from a complaint by an anesthesiologist about a "disturbing situation occurring in several facilities in Alabama where … [a CRNA] was providing epidural steroid injections to patients." The anesthesiologist claimed this practice threatened patient safety and asked the Alabama Board of Nursing to stop it. The state nursing board ruled that the anesthesiologist appeared to have an economic interest in preventing nurses from performing these procedures, said the nurses were authorized to perform them and had been doing so for some time, and told the anesthesiologist to buzz off. The spurned doctor got a more sympathetic hearing from the more physician-centric State Board of Medical Examiners.

As the FTC letter notes, in proposing its pain rule, the Alabama medical board cited no evidence that letting nurses perform the tasks under discussion posed any dangers to patients. What evidence it could find pointed the other way. Earlier this year, the peer-reviewed journal Health Affairs ran an article under the self-explanatory headline "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians." The article drew on the experience of 14 states that let nurse anesthetists work unsupervised by doctors when treating Medicare patients. (The Medicare program has allowed this since 2001, provided the state's governor requests a waiver. According to the Health Affairs article, anesthesiologists successfully fought a version of this rule that didn't require the governor's involvement.)

The notion of allowing nurses and doctors' assistants to perform routine medical tasks in order to reduce medical costs and make certain services more widely available is controversial only to the particular doctors whose economic interests are at stake (and not even always to them). It has no discernable left-right valence, and the FTC has promoted it under presidential administrations both Democratic and Republican. In 2002, for instance, it sued the South Carolina Board of Dentistry when the dental board wouldn't allow hygienists into schools to clean and apply sealants to the teeth of low-income children (a group in whom dentists typically show little interest). The dental board signed a consent agreement five years later. George W. Bush, no regulatory zealot, was in the White House the whole time. When politicians get involved in such fights, the usual reason isn't ideology, but campaign contributions or electoral support from the affected doctors.

Under Obamacare, the need to curb medical inflation will be more urgent than it's been in the past, and almost none of the proposed solutions is as uncontroversial as letting nurses treat pain. But as the Alabama example demonstrates, some government agencies put interest-group needs ahead of consumers', and will throw up regulatory barriers to protect them.

Update, Nov. 12: This column has inspired more than the usual number of critical comments (see below), many from sensible-sounding people. Having reviewed these and then taken a second look at the above, I conclude that while I committed no errors that I know of, I let my readers down in three ways.

First, I should have made clear that while CRNAs are competent to do many things that anesthesiologists do, they are not necessarily competent to do everything that anesthesiologists do. (Even the Alabama nurse's board said CRNAs should not be permitted to make medical diagnoses, and admitted some doubt as to whether CRNAs could handle spinal facet joint injections.) I thought this point would be self-evident, but it wasn't.

Second, I should have clarified the distinction between "non-interventional" pain management such as administering pills, which goes unaddressed in the Alabama medical board's proposed rule, and "interventional" pain management, the somewhat more complicated procedures under discussion here.

Third, I shouldn't have compared the median salary for anesthesiologists ($211,750) with the median salary for registered nurses ($63,750). I should have compared the median salary for anesthesiologists with the median salary for CRNAs, a subset of registered nurses who have received specialized training. In my own defense, I was unable to find such a figure from the Bureau of Labor Statistics. But one commenter dug out an average salary figure of $189,000 from a 2009 survey by Merritt Hawkins & Associates, a health care consulting firm. Mindful that medians vs. averages constitute a poor basis for comparison, I nonetheless concede that if the average salary for CRNAs is $189,000 then the median CRNA salary is probably well into the six figures. The larger point remains. CRNAs make less money than anesthesiologists ($189,000 is less than $211,750), as you'd expect. So allowing CRNAs to perform more tasks performed by anesthesiologists would save money.

Update, Nov. 18: The Alabama State Board of Medical Examiners has "indefinitely postponed" the proposed rule, according to the Nov. 17 Birmingham News, pending completion of two national studies.

Thursday, December 16, 2010

One in three Canadians suffers from chronic pain, which can lead to depression, relationship problems and workplace issues, suggests a new poll.

The SES Research survey found that 16 per cent of those surveyed report living in constant pain, and 20 per cent experience pain on a daily basis.

A family shovels snow. When study participants were asked to rate, between 0 and 10, the following statement: 'My family does not understand how pain affects my life,' 30 per cent scored between seven and 10.(CBC)The telephone poll of 2,000 Canadians was conducted for the Canadian Pain Society from Oct. 10 to 22. Respondents were asked whether they had chronic pain and how they rated the intensity of their pain.

Three hundred people who said they had moderate to severe chronic pain underwent additional in-depth interviews with SES interviewers.

"Pain is clearly having an enormous impact upon the lives of Canadians," said Nikita Nanos, president of SES Research, in a release. " A full third of individuals with moderate to severe pain said that they had lost their job as a result of it and half said that they had seen a reduction in income."

According to the poll, the income loss due to pain was estimated at $12,558 over a one-year time period.

Thirty-three per cent of Canadians surveyed said moderate or chronic pain makes them feel helpless.

It also revealed relationship and family issues associated with pain. When study participants were asked to give a score of between 0 and 10 to the following statement: "My family does not understand how pain affects my life," 30 per cent scored between seven and 10.

As for employment problems associated with chronic pain conditions, 33 per cent of respondents who suffer from moderate or severe chronic pain said they had lost their job as a result of their condition, while 25 per cent strongly agreed with the statement: "I fear my pain will cause me to lose my job."

Following a workplace accident more than four years ago, Donald Anderson was hit with excruciating pain that shot up his left leg.

He turned to surgery, chiropractic, physiotherapy and countless drug treatments; nothing helped. A 20-minute walk would leave him in agonizing pain.

But the 57-year-old Regina man says his pain has decreased by as much as 40 per cent -and his medication by 80 per cent -thanks to a wristwatch-sized device that uses motion-sensor technology similar to what's found in your iPhone or Nintendo Wii.

"Right off the bat, there was a noticeable improvement," Anderson says. "I sleep better, I can sit longer, walk farther -pretty much do everything with less pain than was the case previously."

Anderson and nine other Canadians with chronic pain have been implanted with the technology, developed by Minneapolis-based Medtronic and approved by Health Canada two months ago.

The device -called a RestoreSensor neurostimulator -sends out electric currents to automatically neutralize pain when it senses certain changes in the body's position.

Older models of neurostimulators require the patient to manually adjust the level of stimulation each time posture changes and pressure is shifted.

The motion-sensor technology -triggered in the same way an iPhone screen flips with a simple shift of the wrist -eliminates the need for frequent adjustment.

"It knows the position of the body ... all the time," says Dr. Krishna Kumar, a chronic pain expert and neurosurgeon with nearly 50 years experience who helped develop the technology.

The amount of fluid around each vertebrae of the spinal column changes as the patient sits, stands, walks or lies down, explains Kumar.

"The idea is that we stop the pain messages from getting to the conscious level so the pain will improve, the drug level will come down and the patient will get functionally better," says Kumar.

Kumar says about one per cent of the Canadian population -or 340,000 people -suffer from this kind of pain and could greatly benefit from the technology.

Have you ever struggled to find the best way to ease a child's pain? Do you feel that you lack some of the practical skills needed to deal with children's pain, and also to help children make sense of and deal with their own pain?Now, finally, here is a book that will give you the practical strategies that are based on a sound comprehensive scientific framework. This volume is designed to help pediatric health professionals gain a true understanding of childhood pain. Pain is the most common reason for children to seek a medical consultation – and sometimes is the most common reason for avoiding it. Unaddressed fears and anxiety complicate pain management and recovery. This book comprehensively examines children's fears and anxieties that accompany their need for pain relief, and gives the professional the communication skills and words that can help calm these fears.This book is addressed to all disciplines, and is organized into three parts: Part I explores the scientific understanding of pain as a part of children's development; Part II explores pain treatments themselves, their efficacies and how to combine them for therapeutic impact; and Part III uses this understanding to help translate knowledge into clinical practice in three major arenas of pediatric medicine: the physicians' office, the dentist's office, and in the hospital.

Wednesday, December 15, 2010

Human trials will begin in Australia next year of a new device containing tiny smart chips which is implanted in the spinal cord or other nerves in the body to block pain signals and prevent them reaching the brain.

The smart chip implant technology is officially called Implantable Neuro Sensing and Stimulation or INS2, and is designed to combat chronic pai. It has been developed over the last couple of years by National ICT Australia(NICTA) in Sydney. The development team of 10 includes biomedical experts, electrical and mechanical engineers, software developers, and experts in textile technology.

There are already devices that can be implanted to block pain, but according to NICTA's chief technology officer, Dr. John Parker, these are around the size of a matchbox, whereas the new implant is around the size of a single match head. Dr. Parker said the smaller size improves the reliability of the device and enables it to be implanted closer to the spine.

The new implant consists of one or two smart chips built into a biocompatible device about the size of the head of a match. The device is sewn into a 1.22 mm wide container of a polymer material with integrated electronic wires. The device is then implanted on the target nerve such as the spinal cord or elsewhere in the body. The device is operated by an internal computer processor run by a battery the size of a SIM card that can be recharged wirelessly. Wireless recharging means there is no need for external wires or devices.

The device monitors the properties of the nerves carrying pain signals to the brain and can be "fine-tuned" to block the undesirable pain signals with electrical pulses of up to 10 volts. Since the pain signals no longer reach thebrain, there is little or no sensation of pain. The device will be able to manage different levels of pain in different ways.

NICTA said the device may have numerous applications apart from treating chronic back pain or leg pain, and could be used to block pain caused by nerve damage and migraines. It also has the potential to help control epileptic seizures and the tremors caused by Parkinson's disease.

Tuesday, December 07, 2010

You may not hear them go "Ouch," but fish feel pain just the same, according to a new book by Penn State professor Victoria Braithwaite.

In her book "Do Fish Feel Pain?" (Oxford University Press, 2010), Braithewaite presents her case that fish, like most other organisms, are capable of experiencing pain and that humans can cause fish to suffer.

Here at Discovery News we've covered similar research that concluded lobsters, crab and other shellfish feel pain too. For me, it would be a surprise if they didn't, but scientists have been struggling for ways of proving the obvious here. I think Braithewaite does a good job of summarizing the latest findings.

Braithewaite found that fish have the same kinds of specialized nerve fibers that mammals and birds use to detect noxious stimuli, tissue damage and pain. She also explored whether fish are sentient beings and whether an organism must possess "awareness" to experience pain.

"We now know that fish actually are cognitively more competent than we thought before -- some species of fish have very sophisticated forms of cognition," she said in a press release. "In our experiments we showed that if we hurt fish, they react, and then if we give them pain relief, they change their behavior, strongly indicating that they feel pain."

She was initially drawn to the issue after reading about fish-farming concerns.

"By 2030, half of all fish that humans eat will come from fish farms," she said. "It seemed logical to me to care about fish, because agriculture in general is confronting animal-welfare issues. If we are concerned about animal welfare, we should be concerned about fish welfare."

She believes the United States is 10 years behind Europe now in its thinking about the way it keeps and kills animals in agriculture. Those concerns are just now starting to be extended to aquaculture.

"Electrical stunning may change the way we harvest fish at sea," she said. "We have a responsibility, I think, to make clean and quick kills of fish we eat. Certainly, most of us are not comfortable with piles of fish slowly suffocating on the decks of fishing trawlers at sea and in port. People are rightly asking: 'Isn't there a better way?'"

To do this on a widescale, commercial level, protections related to pain and suffering that are now given to birds and mammals should be widened to include fish.

"There is a perception that fish have simple brains and are incapable of feelings, and this has somehow made them different from birds and mammals when it comes to our concerns for their welfare," she said. "But we now have strong evidence that suggests fish are more intelligent than previously thought and their behavior more complex."

Saturday, December 04, 2010

An international team of scientists have found what they believe could be a novel approach to more effective, targeted relief of chronic pain caused by nerve injuries. The research, a collaboration involving the Universities of Toronto, Seoul, Korea and Bristol, is reported in the latest edition of the journal Science.

Previously, scientists have been able to show that a protein molecule known as PKM zeta is required to store memories. In the case of chronic pain, there is a malfunctioning in the neural process that stores those memories, which prevents the brain from adapting the subsequent behavioural response which would ordinarily allow it to cope with the pain. The connections between neurons through synaptic pathways in the central nervous system are somehow flawed, causing an individual to re-experience pain as the mental record of that pain persists.

This new research has detected the cause for this malfunction and in doing so, has identified a novel target for the treatment of neuropathic pain. By inhibiting PKM zeta in a part of the brain involved in the perception of pain in a mouse model, the international team of scientists have been able to eliminate the painful memory responsible for chronic pain.

Professor Graham Collingridge, from the University of Bristol's MRC Centre for Synaptic Plasticity, the School of Physiology and Pharmacology, and part of the Bristol Neuroscience network, said: "If this translates to humans, it may be possible one day to treat some forms of chronic pain by inhibiting PKM zeta or other molecules involved in the storage of the painful memory. The challenge will be to target the drug so that it inhibits painful memories but not other forms of memory. "

By studying how brain connections operate in a part of the cortex involved in pain sensation in mice, the team found that the molecule PKM zeta actually serves to maintain pain-induced persistent changes in the brain, thereby prolonging the sensation of chronic pain.

The team combined biochemistry, electrophysiology and behaviour to study the role of PKM zeta in the anterior cingulate cortex, a brain region known to be activated in humans during painful states. The identification of a molecular basis for chronic pain provides a framework for the development of more effective therapies in the future.